Chilled Crowds Keep 200+ Ambulances Busy MS agencies in and around the nation_s capitol are used to huge events, but the inauguration of President Barack Obama, which brought some 2 million people to Washington, D.C., Jan. 20, posed special challenges. Besides the tremendous crush of people standing for hours in bone-chilling cold, EMS responders had to deal with the greatest security deployment D.C. has ever experienced.

But months of careful planning, coordination and collaboration among agencies, and hard work for long hours by hundreds of EMTs and paramedics, allowed EMS to respond to more than 1,800 calls and transport nearly 250extra patients between 4 a.m. and 4 p.m. that day. (D.C. Fire & EMS [DCFEMS] normally receives some 450 EMS calls and transports approximately 270 patients each day.)

To supplement the 39 ambulances and 14 standby units fielded by DCFEMS, the city declared an emergency, allowing activation of FEMA_s national disaster ambulance contract with AMR.

"We wanted to ensure our 39 units remained untouched for citywide [day-to-day] responses, so we put out a request to the National Capitol Region for six EMS strike teams from Maryland andNorthern Virginia," says DCFEMS Deputy Chief of Operations Larry Schultz. "We still felt we_d fall short, so we put in a request throughFEMA for 120 ambulances forstandby." Disaster Medical Assistance Teams (DMATs) from several states also came in to help, andpark rangers from around the U.S. staffed 16 medical tents on the Mall. "We also had bike teams and 30 Gator teams out there," Schultz says. Maryland EMS Director Bob Bass, MD, says his state deployed four strike teamsƒeach with four ambulances plus a strike team leaderƒto D.C. from 6 a.m. to 9 p.m. that day. "We had 30 ambulances from FEMA in Maryland for backfill and 50 more on standby, and D.C. had 60 from FEMA running," he says.

DCFEMS Medical Director Jim Augustine, MD, says, "With our own fleet handling the normal, day-to-day calls, this fleet was brought in, placarded and oriented, and put into the dispatch system as units reserved for inaugural activities."

Out-of-town ambulances were staged at four sites convenient to the Mall and parade route. "When it got very, very busy, it was difficult to handle responses over the radio because they came in such clumps," Augustine says. "So we went to dispatching units off the ramp. One captain would pass on information on five or six calls and hand-dispatch each medic unit who would respond to those calls.

"We had a DCFEMS firefighter/EMT riding on the vast majority of mutual-aid and AMR vehicles to ensure radio communications and guide the units; we didn_t want people using map books," he says. "Then every unit could go to an assigned frequency for theEMS liaison officer who would assign a transport destination."

According to Augustine, the majority of inauguration-related calls were for hypothermia, "exacerbation of asthma from walking long distances in crowds and the cold," diabetic emergencies, chest pains, and respiratory and cardiovascular problems. EMS also responded to three cardiac arrests, at least one of which was a save.

"We had a lot of slip-trip-and-fall [patients] and some anxiety patients," Schultz says. "For example, the Third Street tunnel that goes under the Mall got filled up quick, and some people began tofeel claustrophobic and panicked, so we had to get in and help."

But Augustine_s worst fearƒa "crushing event" caused by a panicked crowdƒnever materialized. Further, Schultz says, "I don_tthink we had a single run for violence."

Future planning for such events should focus more attention on the problems created by tight security, Augustine says. "People came very early [and weren_t allowed to carry] backpacks, blankets, food or water, the things people would usually bring for an outing when it_s in the teens. And then we sometimes had difficulty getting our people through."

Schultz adds, "Our after-action plan must look at a more robust plan for warming." Although some federal buildings were open for that purpose, "the number of people needing warming overwhelmed those buildings, so the medical tents were flooded with people coming in to get warm."

According to Schultz, EMS inaugural planning began June 1, 2008, when he assigned three people to a Secret Service planning team. In mid-November, DCFEMS assembled an internal incident management team that included EMS top brass. Besides working with federal and local officials, DCFEMS also integrated EMS leaders from Maryland and Northern Virginia into the planning and deployment. Both Maryland and Virginia stationed EMS representatives in the D.C. Office of Unified Communications on inauguration day to help track ambulances and hospital status in the entire region. Because of this, area hospitals never became overwhelmed.

"It was very well coordinated," Bass says. "We hope this lays the groundwork for us to track hospital and EMS-system status across the region on a day-to-day basis." ƒMannie Garza

Paramedics Use UltrasoundThe Littleton, Colo., and Odessa, Texas, fire departments have trained paramedics to use handheld ultrasound in the field. Littleton Fire Rescue (LFR) put two SonoSite handheld ultrasounddevices into the field in 2006 with stern warnings to paramedics not to drop the $10,000 transducers. The Odessa Fire Department (OFD) has been using the devices since 2000. They have trained 25 paramedics, and all ambulances carry the devices.

"We trained 15 people on two of our busiest medic units," says LFR EMS Chief Wayne Zygowicz. But he reports training was a challenge, because paramedics must look at a lot of images to become proficient in reading them. "We did a ton of images before [the crews] were comfortable."

OFD Medical Director David Spear, MD, says, "Some people are intimidated; some people pick it up." Spear sees prehospital ultrasound being as useful as an ECG. "You can scan to see if [an injury or pain] is a really, really bad thing," he says, adding, "Sloshing belly blood in the back of an ambulance is easier to view."

Zygowicz cites two examples of how the ultrasound "made a big difference in people_s lives." A girl who fell off a horse was waiting in the emergency department during a particularly busy time. The paramedic involved approached a doctor with the ultrasound he_d done in the ambulance, saying, "You might want to look at this." The image of the girl_s bleeding spleen took her to the top of the triage list.

LFR paramedics used another ultrasound performed in the field to diagnose an ectopic pregnancy in a woman complaining of abdominal pain.

According to Spear, performing an ultrasound "takes about 60 seconds, if [the provider has used the device regularly]." He_d like OFD paramedics to use the five devices more frequently than they do, including on all patients with significant trauma.

After 18 months of testing the devices, Zygowicz concluded that ultrasound is more fitting for air ambulances and ground services with long transport times than for LFR. With five hospitals and a Level 1 trauma center within a 10-mile radius, LFR_s transport times are very short. "It_s not a priority skill with short transport times; [there_s] just not enough time to do it," he says.

"Most of the time, medics have too many other things to do," says Dylan Luyten, MD, an emergency physician at Swedish Medical Center in Denver who was the LFR medical directorduring the study. But Luyten still sees potential for ultrasound, especially for identifying ectopic pregnancies and abdominal aortic aneurysms in the field.ƒAnn-Marie Lindstrom

Pro BonoDon_t Count onImmunity LawsA study published Jan. 15 in the American Medical Association_s journal Disaster Medicine and Public Health Preparedness notes that the U.S. lacks clear liability protections for emergency medical responders. "Good Samaritan" or "Qualified Immunity" laws are established on a state-by-state basis to provide limited liability protectionto emergency responders acting in that capacity (e.g., as EMTs orparamedics) and liability protection for citizens and other health professionals who assist soon after an emergency occurs. However, these laws generally haven_t kept up with the changing times.

Immunity from liability is established by state statute, and every state is different. Some states provide blanket "protection" from liability for patient-care activities for all providers (career and volunteer), but others only cover "volunteers." Some states include immunities for disaster-response situations, while others do not. EMS providers from government agencies often enjoy greater immunity protection than those who work for private EMS agencies.

The key: You must check your state_s laws carefully to determine if you_re covered and exactly what degree of liability protection you have.

In 1996, The National Association of State EMS Officials drafted model immunity language for states to consider as part of the National Conference of Commissioners on Uniform State Laws_ "Uniform Emergency Volunteer Health Practitioners Act." This model legislation was approved and recommended for enactment in all 50 states, but states have been slow to act.

In addition, no state immunity laws will prevent a lawsuit for negligence, although they may give you an added "defense" against liability if you_re sued. Most immunity statutesƒif applicable to your situationƒwill raise the negligence standard from "ordinary negligence" (the failure to act as a reasonable EMS provider would act under similar circumstances) to that of "gross or willful negligence" (meaning you must act with willful disregard for the consequences of your actions). Gross or willful negligence is much harder for the plaintiff to prove in court.

To protect yourself:

Always function within your "scope of practice" or certification level;

Function in accordance with the accepted protocols in your EMS community;

Seek medical command or input from your medical director when you_re in doubtƒthe system medical director is a good source because they_re ultimately responsible for how emergency medical care is provided in your community; and

Fully and accurately document your assessment and care of every patient.

Even if your state has immunity laws, never rely on them to determine how you conduct yourself as an EMS responder.

Pro Bono is written by attorneysDoug WolfbergandSteve WirthofPage,Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm_s Web site atwww.pwwemslaw.com for more EMS law information.

Quick TakesArmy Puts WoundStat on HoldIn October, the U.S. Army distributed some 18,000 packets of WoundStat to soldiers fighting in Iraq and Afghanistan after a U.S. Army Institute of Surgical Research study concluded that the product_s granules poured into wounds were better than other hemostatic products at controlling bleeding and saving lives. But two months later, after another study concluded WoundStat could cause harmful blood clots, the Army Medical Command warned medics not to use the granules until more testing determines whether it_s safe. WoundStat manufacturer, Trauma Cure Inc., told the Associated Press it would cooperate with the U.S. military on more research. But the company stressed that the new study involved putting the granules on surgical incisions in pigs, adding, "There have been no reported incidents or adverse outcomes in humans."

FEMAon YoutubeFEMA joined YouTube in March 2006, and by Feb. 10, 2009, the channel had 159 subscribers and had generated 16,481 page views. The most popular of the 54 videos posted on www.youtube.com/fema was the seven-minute Jan. 14, 2009, farewell message from retiring FEMA Administrator David Paulison, "Where FEMA Was, Is Now, and Where It Is Going." When he took the job after Hurricane Katrina, he found FEMA_s employees dedicated and highly motivated, but with low morale due to poor leadership and a lack of staff and funding. He tapped professionals he knew to provide new leadership for FEMA and won support from Congress to hire more people, more than doubling the size of FEMA from less than 1,500 employees to almost 4,000.

ControversyShould EMS Draw Blood for DWI Testing?The Texas legislature is considering a bill that would allow EMT-intermediates and paramedics to honor a police officer_s request to draw blood to see if someone is driving while intoxicated (DWI). Current Texas law explicitly excludes EMS personnel from such blood draws. The legislation would also remove language requiring blood to be drawn "in a sanitary place," although it provides liability protection only if the specimen is "taken according to recognized medical procedures." Does your state allow EMTs and paramedics to do DWI tests? Do you think paramedics should draw blood at highway scenes? EMT-Is? EMT-Bs?